Fire Fighter Collapses at the Fire House and Subsequently Dies due to Heart Arrhythmia Secondary to Mycocardial Sarcoidosis - New Jersey

SUMMARY

On November 16, 1999, a 38-year-old male Fire Fighter awoke
at 0100 hours due to severe upper abdominal pain. While being transported to a
local hospital, the victim suffered a seizure, followed shortly thereafter by a
cardiac arrest in the hospital parking lot. Despite cardiopulmonary
resuscitation (CPR) and advanced life support (ALS) administered in the hospital’s
emergency department, the victim died. An autopsy of the victim revealed an
enlarged heart and granulomatous lesions consistent with sarcoidosis in the
victim’s heart, lung, lymph nodes, liver, and spleen. There was no evidence of
coronary artery disease or evidence for a heart attack (myocardial infarction).

Other agencies have proposed a three-pronged strategy for
reducing the risk of on-duty sudden cardiac death among fire fighters. However,
it is unclear if any of these recommendations would have prevented this Fire
Fighter’s death. This strategy consists of: 1) minimizing physical stress on
fire fighters; 2) screening to identify and subsequently rehabilitate high risk
individuals; and 3) encouraging increased individual physical capacity. Issues
relevant to this Fire Department (FD) include:

Fire Fighters should have annual medical evaluations to
determine their medical ability to perform duties without presenting a
significant risk to the safety and health of themselves or others. The
Department and Union should negotiate the content and frequency to be
consistent with NFPA 1582.

Abnormal findings uncovered during annual medical
evaluations should be medically evaluated. If this follow-up medical
evaluation is conducted by the fire fighter’s personal physician, results
should be reviewed by the fire department physician to determine the fire
fighter’s medical ability to perform duties without presenting a significant
risk to the safety and health of themselves or others.

Reduce risk factors for cardiovascular disease and
improve cardiovascular capacity by phasing in a mandatory wellness/fitness
program negotiated between the Fire Department and the Union.

INTRODUCTION AND METHODS

On November 11, 1999, a 38-year-old male Fire Fighter
experienced the acute onset of severe upper abdominal pain and shortly
thereafter died. NIOSH was notified of this fatality on November 30, by the
United States Fire Administration. On February 14, 2000, NIOSH contacted the
affected Fire Department to initiate the investigation. On June 21, 2000, a
physician and an epidemiologist from the NIOSH Fire Fighter Fatality
Investigation Team traveled to New Jersey to conduct an onsite investigation of
the incident.

During the investigation NIOSH personnel met with and
interviewed the

• Chief of the FD;

• Deputy Chiefs of the FD;

• Local President of the International Association of
Fire Fighters (IAFF);

• Crew members on-duty at the time of the incident;

• Victim’s parents.

During the site-visit NIOSH personnel also reviewed:

• Existing FD investigative records;

• The victim’s FD training records;

• The victim’s required Hazmat medical evaluations;

• Emergency medical services - ambulance report;

• Hospital emergency department records of the
resuscitation effort;

• Death certificate;

• Autopsy;

• FD policies and operating procedures;

• The FD annual run report for 1999.

INVESTIGATIVE RESULTS

Incident. On November 15, 1999, three fire fighters
and their officer began their 24-hour shift at 0800 hours. During the day the
crew responded to three calls (two medical emergencies and one false alarm). At
approximately 0100 hours, the crew members were awakened by the victim writhing
in pain on the floor, holding his upper abdomen, complaining of "stomach
pain." At 0112 hours dispatch received a medical emergency call from the
fire house and dispatched an ambulance, which arrived at the 0116 hours. Upon
the ambulance’s arrival, the victim’s pain had subsided, he was conversant,
and vital signs were stable. In addition to his abdominal pain, the victim
described a mild numbness in both hands.

At 0132 hours the ambulance departed the fire house for the
local hospital’s emergency department. While en route, at approximately 0134
hours, the victim suffered what was described by emergency medical technicians
as a seizure. As the ambulance arrived at the hospital at 0135 hours, the victim
was unresponsive, with agonal breathing and no pulse. An oral airway was
inserted and he was "bagged" with 100% oxygen as he was rushed into
the emergency department. CPR was initiated and ACLS administered by hospital
personnel was begun. This included intubation (a breathing tube place into the
victim’s windpipe), external defibrillation (shocking the heart using
paddles), intravenous administration of medications, and the placement of a
temporary pacemaker. After approximately 60 minutes in the emergency department,
the victim was pronounced dead at 0230 hours, and resuscitation efforts were
discontinued. The victim did not have a history of any previous abdominal or
chest pain, nor did he complain of any pain earlier in his shift.

Medical Findings. The death certificate was completed
by the medical examiner but the cause of death was deferred until autopsy
results were available. Autopsy findings were significant for:

The final autopsy report listed "granulomatous
myocarditis due to sarcoidosis, generalized" as the cause of death.

Review of the victim’s medical records indicated that at
the FD’s pre-employment medical evaluation seven years previously the victim
had a normal chest X-ray (CXR), normal lung function (spirometry), and some
abnormalities on electrocardiogram (EKG) (left ventricle hypertrophy by voltage,
peaked T waves in leads V-2 and V-3, and up-sloping ST segment elevation in
V-3-V-6). These EKG abnormalities were interpreted as consistent with an
"athletic heart" in a fit, asymptomatic 31-year-old-man. In 1996, the
victim had periodic FD medical evaluation as required for HAZMAT duty. This
medical evaluation reported similar CXR, lung function [pulmonary function tests
(PFTs)], and EKG findings. However, in 1998, the victim’s HAZMAT medical
evaluation showed several changes. His CXR suggested enlarged right paratracheal
and right bronchopulmonary lymph nodes. His PFTs were still within
"normal" range, but a significant was noted from his previous test in
1996. His EKG was unchanged. The examining physician cleared him for duty, but
noted he needed close follow-up of these changes, specifically a chest
"CAT" scan with his private physician. There is no evidence at this
time of this investigation that the victim sought further medical evaluation
after this evaluation.

DESCRIPTION OF THE FIRE DEPARTMENT

At the time of the NIOSH investigation, the fire department
was comprised of 590 uniformed personnel and served a population of 232,000
residents, in a geographic area of 21 square miles. There are 16 fire stations
where fire fighters work the following tour of duty: 24 hours on, 72 hours off.
Each shift of an engine company is staffed with an officer and three fire
fighters. Each shift of a ladder company is staffed with an officer and three
fire fighters. Throughout the day, the victim did not report or show any signs
of discomfort, pain, or distress. The victim went on three responses, two
medical calls and one false alarm call that shift.

Training. The fire department provides all new fire
fighters with the basic 8-week training to become certified to the National Fire
Protection Association (NFPA) Fire Fighter II level. All are State-certified
First Responders and are certified in CPR, defibrillator, and hazardous
materials operations. The department also conducts monthly training. The victim
had seven years of fire fighting experience and was a NFPA-certified Fire
Fighter II and a HAZMAT technician.

Pre-employment/Pre-placement Evaluations. The
department requires a pre-employment/pre-placement medical evaluation for all
new hires, regardless of age. Components of this evaluation for all applicants
include:

These evaluations are performed by a City contract physician,
who makes a decision regarding medical clearance for fire fighting duties. The
results of the medical examination are kept confidential by the contract
physician and only the clearance status is reported to the County Fire
Department. New hires are also required to complete a physical agility test.
This is a timed performance evaluation of typical fire fighting duties.

Periodic Evaluations

Other than for HAZMAT responders, annual medical evaluations
are optional for Fire Fighters. Components of this "optional"
evaluation include:

These evaluations are also performed by the City contract
physician who makes a decision regarding medical clearance for fire fighting
duties. The FD estimated that approximately 5% of the fire fighters participate
in this voluntary medical evaluation program. If an employee is injured at work,
he/she must be cleared for "return to work" by the City contract
physician. If an employee has been on sick leave for more than 3 consecutive
calendar days, he/she must also be cleared for "return to work" by the
City contract physician if the illness was work related or by their personal
physician if the illness was of a non-work related nature. Most stations have
exercise (strength and aerobic) equipment, purchased by the fire fighters, but
there is no fitness program in place.

DISCUSSION

Sarcoidosis is a chronic, multisystem disorder of unknown
etiology (cause). It is characterized by the accumulation of inflammatory cells
(T-helper lymphocytes and mononuclear phagocytes), followed by the formation of
"noncaseating epithelioid granulomas," (a term used by pathologists to
describe the microscopic lesions), which can disrupt the normal tissue structure
and function. The lung and lymph nodes are most commonly involved, but other
organs can be affected including the skin, eyes, and heart. The clinical course
of the disease is variable, ranging from acute onset, typically involving
respiratory symptoms, to a chronic disease with symptoms that wax and wane over
many years. As in the case of this fire fighter, some cases are completely
asymptomatic and are only identified by chest X-ray.1

The characteristic histologic (microscope) lesions are
typically found on lung biopsy. Although the histologic findings are required
for a definitive diagnosis, noncaseating granulomas are not specific to
sarcoidosis and are found in a number of other diseases, including infections
and malignancies. Thus, the diagnosis of sarcoidosis is made by a combination of
clinical, radiographic (X-rays), and histologic (microscope) findings.1

The incidence and prevalence of sarcoidosis in the United
States vary by race, gender, and age.2-8 The study which
best adjusted for these demographic variables was published by Rybicki et al. in
1997.2 They conducted a longitudinal cohort study of newly
diagnosed cases between 1990 and 1994 among members of a health maintenance
organization in Detroit, Michigan. They found the following demographic
variables as being independent risk factors for sarcoidosis:

African-American race [relative risk (RR)=3.8];

Female gender (RR=1.3);

Ages 30-39 years (RR=1.7);

Ages 40-49 years (RR=1.4)

As mentioned earlier, the cause of sarcoidosis is unknown,
but environmental, infectious, and genetic risk factors has been hypothesized as
etiologic agents. Fire fighters have been reported to have relatively high rates
(discussed below), presumably due to their exposure to a variety of toxins in
smoke or exposure to communicable diseases while performing their duties as
first responders.3, 9 The first report, published by Kern
et. al. in 1993, investigated a cluster of three cases of sarcoidosis among ten
white fire fighters who trained together as apprentices in 1979.9
A subsequent case finding questionnaire survey of 1,282 active and retired male
fire fighters and police officers, followed by a medical evaluation, found one
additional case for an overall point prevalence of 312 per 100,000. This point
prevalence is higher than the general population point prevalence of 17 per
100,000 for whites and 64 per 100,000 in blacks collected 30 years earlier.8

Prezant and colleagues conducted a longitudinal cohort study
of newly diagnosed cases between 1985 and 1998 among New York City (NYC) fire
fighters.3 Using chest X-rays taken during periodic
wellness medical evaluations and requiring cases to be biopsy-proven, Prezant et
al. found an annual incident rate of 12.9 cases per 100,000 among white fire
fighters. This rate is higher than the incident rate of age-adjusted biopsy
proven cases of sarcoidosis in white males (5.9 per 100,000 per year) or of
age-adjusted biopsy and clinical cases of sarcoidosis in white males (9.6 per
100,000 per year).2 Unfortunately, this finding could be
due to the following differences between the two studies: case ascertainment
(active versus passive), case definitions (biopsy versus clinical), and age
distributions (not age-adjusted versus age-adjusted). Looking specifically at
the age distribution, Rybicki et al. found the incidence rates among white males
to be highest among the 40-49 years old group (24 per 100,000 per year),
followed by the 30-39 year old group (22 per 100,000 per years) and the 20-29
year old group (12 per 100.000 per year).2 Using these age
specific rates as the comparison group (typical ages of active duty fire
fighters), the incident rates of NYC fire fighters do not appear elevated.

Among patients diagnosed with sarcoidosis, granulomatous
lesions in the heart have been found in approximately 15% of patients.10-12
Cardiac involvement is clinically recognized in about 5% of known sarcoid
patients, and subclinical (identified at autopsy) in the other 10%. Both groups
are at increased risk of sudden death, conduction abnormalities (bundle branch
blocks, partial and complete heart block), arrhythmias (ventricular and
supraventricular), and congestive cardiomyopathy.10-19 In
fact, as in the case of this fire fighter, sudden cardiac death is the most
common first manifestation of cardiac sarcoidosis.12-15
The victim’s acute onset of upper abdominal pain has not been reported as a
presentation of sarcoidosis. Most likely, this pain was cardiac in origin,
probably secondary to some type of arrhythmia.

To ensure that candidates and current fire fighters are
medically capable of performing their required tasks and to reduce the risk of
occupational injuries and illnesses, the National Fire Protection Association (NFPA)
has developed guidelines entitled "Medical Requirements for Fire Fighters
and Information for Fire Department Physicians," otherwise known as NFPA
1582.20 These guidelines, updated in 2000, specifies
minimum medical requirements for candidates and current fire fighters. Although
sarcoidosis is not specifically mentioned, the guideline does address the effect
sarcoidosis can have on the various organs (e.g. lungs, heart). For example, the
victim had left ventricular (heart) hypertrophy diagnosed by EKG. NFPA 1582
considers hypertrophy of the heart (enlarged heart) a Category B Medical
Condition is defined as "a medical condition that, based on its severity or
degree, could (our emphasis) preclude a person from performing as
a fire fighter in a training or emergency operational environment by presenting
a significant risk to the safety and health of the person or others." Given
the victim’s fitness level, lack of symptoms, and low normal PFTs, the
decision to clear the victim for fire fighting duties in 1998 was consistent
with NFPA guidelines. The recommendation that the victim seek further evaluation
of his abnormal CXR, EKG, and recent drop in his lung function with his private
physician is also consistent with NFPA guidelines and standard medical care.
However, the Fire Department physician should have followed up the case to
ensure that the fire fighter was subsequently evaluated, and to review the
subsequent tests. With this information, the Fire Department physician could
have updated the fire fighter’s medical clearance for full duty.

Annual medical evaluations are also recommended by NFPA 1582
and the International Association of Fire Fighters/International Association of
Fire Chiefs (IAFF/IAFC) wellness/fitness initiative.21
Perhaps, if this FD required annual medical evaluations, and the FD physician
re-emphasized the need to for follow-up, the victim may have sought further
medical evaluation by his personal physician. This would probably have led to a
transbronchial biopsy, a diagnosed of sarcoidosis, and probably treatment with
corticosteroids. This may have prevented his sudden cardiac death.

RECOMMENDATIONS AND DISCUSSION

The following recommendations address health and safety
generally. This list includes some preventive measures that have been
recommended by other agencies to reduce the risk of sudden cardiac arrest and or
death among fire fighters. However, it is unclear if any of these
recommendations would have prevented this Fire Fighter’s death. In addition,
these recommendations have not been evaluated by NIOSH, but represent research
presented in the literature or of consensus votes of Technical Committees of the
National Fire Protection Association or labor/management groups within the fire
service. This strategy consists of: 1) minimizing physical stress on fire
fighters; 2) screening to identify and subsequently rehabilitate high risk
individuals; and 3) encouraging increased individual physical capacity. Issues
relevant to this Fire Department (FD) include:

Recommendation #1: Fire Fighters should have annual medical
evaluations to determine their medical ability to perform duties without
presenting a significant risk to the safety and health of themselves or others.
The Department and Union should negotiate the content and frequency to be
consistent with NFPA 1582.

Guidance regarding the content and frequency of periodic
medical evaluations for fire fighters can be found in NFPA 1582, Medical
Requirements for Fire Fighters20 and in the report of the
International Association of Fire Fighters/International Association of Fire
Chiefs (IAFF/IAFC) wellness/fitness initiative.21

Applying the above NFPA standard involves legal and economic
repercussions and must be carried out in a nondiscriminatory manner. Appendix D
of NFPA 1582 provides guidance for Fire Department Administrators regarding
legal considerations in applying the standard.

Economic repercussions go beyond the costs of administering
the medical program. Department administrators, unions, and fire fighters must
also deal with the personal and economic costs of the medical testing results.
NFPA 1500 addresses these issues in Chapter 8-7.1 and 8-7.2.22
The success of medical programs may hinge on protecting the affected fire
fighter. The department should provide alternate duty positions for fire
fighters in rehabilitation programs, if possible. If the fire fighter is not
medically qualified to return to duty after repeat testing, supportive and/or
compensated alternatives for the fire fighter should be pursued by the
Department. Other than for the statement regarding duty status, these medical
records should be kept confidential.

Recommendation #2: Abnormal findings uncovered during annual
medical evaluations should be medically evaluated. If this follow-up medical
evaluation is conducted by the fire fighter’s personal physician, results
should be reviewed by the fire department physician to determine the fire
fighter’s medical ability to perform duties without presenting a significant
risk to the safety and health of himself or others.

NFPA 1582 requires all evaluations completed by outside
physicians be reviewed and approved by the Fire Department physician (Chapter
2-2.5.1 and Chapter 2-4.1.1).20

OSHA’s Revised Respiratory Protection Standard requires
employers to provide medical evaluations and clearance for employees using
respiratory protection.23 These clearance evaluations are
required for private industry employees and public employees in States operating
OSHA-approved State plans. Since New Jersey is a State-plan State, public sector
employers are required to comply with OSHA standards. A copy of the OSHA medical
checklist has been provided to the Fire Department and should not involve a
financial burden to the Fire Department beyond that required for the
fitness-for-duty medical evaluation.

Recommendation #4: Reduce risk factors for cardiovascular
disease and improve cardiovascular capacity by phasing in a mandatory
wellness/fitness program negotiated between the Fire Department and the Union.

NFPA 1500, Standard on Fire Department Occupational Safety
and Health Program, requires a wellness program that provides health promotion
activities for preventing health problems and enhancing overall well-being.22
In 1997, the International Association of Fire Fighters (IAFF) and the
International Association of Fire Chiefs (IAFC) joined in a comprehensive Fire
Service Joint Labor Management Wellness/Fitness Initiative to improve fire
fighter quality of life and maintain physical and mental capabilities of fire
fighters. Ten fire departments across the United States joined this effort to
pool information about their physical fitness programs and to create a practical
fire service program. They produced a manual and a video detailing elements of
such a program.21 The Fire Department should review these
materials to identify applicable elements. Other large-city negotiated programs
can also be reviewed as potential models.

21. International Association of Fire Fighters and the
International Association of Fire Chiefs [1997]. The fire service joint labor
management wellness/fitness initiative. International Association of Fire
Fighters, Department of Occupational Health and Safety, Washington DC, 1997.

This investigation was conducted by and the report written by Kristen Sexson,
MPH, Epidemiologist and Thomas Hales, MD, MPH, Occupational and Internal
Medicine Physician. Ms. Sexson and Dr. Hales are with the NIOSH Fire Fighter
Fatality Investigation and Prevention Program, Cardiovascular Disease Component
located in Cincinnati, Ohio.